title: Epidural application of spinal instrumentation particulate wear debris: a comprehensive evaluation of neurotoxicity using an in vivo animal model.
abstract: OBJECTIVE
  The introduction and utilization of motion-preserving implant systems for spinal reconstruction served as the impetus for this basic scientific investigation. The effect of unintended wear particulate debris resulting from micromotion at spinal implant interconnections and bearing surfaces remains a clinical concern. Using an in vivo rabbit model, the current study quantified the neural and systemic histopathological responses following epidural application of 11 different types of medical-grade particulate wear debris produced from spinal instrumentation.
  
  
  METHODS
  A total of 120 New Zealand White rabbits were equally randomized into 12 groups based on implant treatment: 1) sham (control), 2) stainless steel, 3) titanium alloy, 4) cobalt chromium alloy, 5) ultra-high molecular weight polyethylene (UHMWPe), 6) ceramic, 7) polytetrafluoroethylene, 8) polycarbonate urethane, 9) silicone, 10) polyethylene terephthalate, 11) polyester, and 12) polyetheretherketone. The surgical procedure consisted of a midline posterior approach followed by resection of the L-6 spinous process and L5-6 ligamentum flavum, permitting interlaminar exposure of the dural sac. Four milligrams of the appropriate treatment material (Groups 2-12) was then implanted onto the dura in a dry, sterile format. All particles (average size range 0.1-50 μm in diameter) were verified to be endotoxin free prior to implantation. Five animals from each treatment group were sacrificed at 3 months and 5 were sacrificed at 6 months postoperatively. Postmortem analysis included epidural cultures and histopathological assessment of local and systemic tissue samples. Immunocytochemical analysis of the spinal cord and overlying epidural fibrosis quantified the extent of proinflammatory cytokines (tumor necrosis factor-α, tumor necrosis factor-β, interleukin [IL]-1α, IL-1β, and IL-6) and activated macrophages.
  
  
  RESULTS
  Epidural cultures were negative for nearly all cases, and there was no evidence of particulate debris or significant histopathological changes in the systemic tissues. Gross histopathological examination demonstrated increased levels of epidural fibrosis in the experimental treatment groups compared with the control group. Histopathological evaluation of the epidural fibrous tissues showed evidence of a histiocytic reaction containing phagocytized inert particles and foci of local inflammatory reactions. At 3 months, immunohistochemical examination of the spinal cord and epidural tissues demonstrated upregulation of IL-6 in the groups in which metallic and UHMWPe debris were implanted (p < 0.05), while macrophage activity levels were greatest in the stainless-steel and UHMWPe groups (p < 0.05). By 6 months, the levels of activated cytokines and macrophages in nearly all experimental cases were downregulated and not significantly different from those of the operative controls (p > 0.05). The spinal cord had no evidence of lesions or neuropathology. However, multiple treatments in the metallic groups exhibited a mild, chronic macrophage response to particulate debris, which had diffused intrathecally.
  
  
  CONCLUSIONS
  Epidural application of spinal instrumentation particulate wear debris elicits a chronic histiocytic reaction localized primarily within the epidural fibrosis. Particles have the capacity to diffuse intrathecally, eliciting a transient upregulation in macrophage/cytokine activity response within the epidural fibrosis. Overall, based on the time periods evaluated, there was no evidence of an acute neural or systemic histopathological response to the materials included in the current project.
authors.affiliation: Orthopaedic Spinal Research Institute, University of Maryland St. Joseph Medical Center, Towson, USA. bcspine@gmail.com
authors.forename: Bryan W
authors.initials: BW
authors.lastname: Cunningham
authors.forename: Nadim J
authors.initials: NJ
authors.lastname: Hallab
authors.forename: Nianbin
authors.initials: N
authors.lastname: Hu
authors.forename: Paul C
authors.initials: PC
authors.lastname: McAfee
mesh_terms: D000818:Animals; D016207:Cytokines / Q000037:antagonists & inhibitors / Q000096:biosynthesis; D004731:Endotoxins / Q000633:toxicity; D004824:Epidural Space / Q000187:drug effects / Q000473:pathology; D005355:Fibrosis / Q000139:chemically induced / Q000473:pathology; D008159:Lumbar Vertebrae / Q000187:drug effects / Q000473:pathology / Q000601:surgery*; D008262:Macrophage Activation / Q000187:drug effects; D023421:Models, Animal; D009498:Neurotoxins / Q000633:toxicity*; D019637:Orthopedic Procedures / Q000009:adverse effects* / Q000295:instrumentation* / Q000592:standards; D052638:Particulate Matter / Q000009:adverse effects*; D019736:Prostheses and Implants / Q000009:adverse effects* / Q000592:standards; D011817:Rabbits; D011897:Random Allocation; D013116:Spinal Cord / Q000187:drug effects / Q000473:pathology / Q000601:surgery*
chemical_list: D016207:Cytokines; D004731:Endotoxins; D009498:Neurotoxins; D052638:Particulate Matter